The purpose of this blog is to gather information about how to support caregivers of children. The quality of the caregiving relationship in infants and young children, central to the healthy development of the growing child, can be enhanced by attention to the caregivers in the form of education and other support. This blog will become an archive for information on these issues.

Tag Archives: transitions

Important Note: The image in this post and in all the previous ones are not images of the children discussed in the posting. They are simply children whose photos I have collected throughout my travels.

It is back to school time again. Returning to school after summer vacation is a major transition. We have talked about transitions and what a challenge they are for everybody, especially for young children and vulnerable children of any age. Here are some ideas about how to make back to school time easier for everyone.

Try to Be Calm and Relaxed

Parents’ communication of anxiety to their child plays a significant role in the anxiety experienced by the child. Evidence for this influence is presented in a recent review of 15 studies addressing the question of the extent to which fear-relevant features of parental verbal communications affected the child (Percy et al, 2016). However, scientific studies are not necessary to convince teachers of this fact. Observations in a typical classroom offer support for this important dynamic. For example, I observed a father dropping off his 4-year old daughter, giving her a hug, and asking her, “Will you be all right, now?” She said, “Yes, Daddy.” The father responded, “Are you sure?”

In fact, much of this communication occurs nonverbally in parents’ behavior – such as lingering in the classroom, returning to the child after the initial good bye to add some information or give some advice. After the child is in the hands of the teacher, it is almost never a good idea for the parent to return if the child complains or even cries.

Positive Communication

For young child, the most effective way parents can support him or her at drop off is to communicate positive feelings about the experience, to “hand off” the child to a teacher, and to leave. For example, a parent might find a teacher and in the child’s presence tell the teacher something about the ride to school or the child’s excitement about the class activity planned for the day, reassure the child about who is picking up the child and when, give the child a hug, and say good bye.

Child’s anxiety

All children have some anxiety about returning to school – usually to a new classroom, a new teacher, and new classmates. Children express their anxiety in different ways. Most young children express their anxiety verbally and by clinging to a parent. Other children express it by running from one activity to another in a dysregulated manner. And others become more constrained, holding themselves in, sitting quietly and avoiding taking risks.

Some children are particularly vulnerable to separations and transitions and need extra support. Some need to bring a comforting object from home to help with the transition (although that object must usually be put away after the class begins). A goodbye ritual is helpful to all children. The parent can help the child hang up her coat, check the schedule for the day, wash her hands, etc. In some of the classrooms of the preschool where I work there is a “goodbye window” where parents can say another goodbye after they have exited the school building.

Listening to Your Child

Communicating positive expectations to the child does not mean that the parent – or teacher – refuses to listen to the child’s concerns. No matter how unrealistic the child’s fears might be, the adult must take them seriously as fears – not as reality – and validate them. For example, the child may say, “You won’t come to pick me up!” The parent must respond with some kind of acknowledgement of the child’s fear that he will be abandoned in this scary place, while also reassuring him that his fears are unjustified. For example, she might say, “That is such a scary thought, that I wouldn’t pick you up. I know you are scared. But you know that I really will pick you up at lunchtime and that Ms. Smith (the teacher) will take good care of you until then. You are going to have a cooking activity today. You know how much you love that!”

Familiarity with the School

Familiarity with the school helps too. Most schools have visiting days, but some children need time to familiarize themselves with the school without the noise and activity of many other children and parents. Other ways to help the child feel comfortable include coming to the school when it is not in session and playing on the playground (if that is permitted) or walking around the building and pointing out where the child’s classroom is located, where the parent will bring the child and pick her up.

Get to School On Time

Getting to school on time is important for many reasons. At the beginning of the school day the teachers have more availability to greet the child and parent than when groups of children and parents descend on the classroom. The classroom is less noisy and has less physical activity – sensory challenges that are particularly hard for some children. Being rushed does not lend itself to a positive good bye. Also, teachers usually plan “free play” time at the beginning of the day, and if children come to class late, they miss that important and enjoyable time.

I find myself talking about transitions to the parents I see perhaps more than anything else. A parent will say, for example, “When I call her to come to dinner and finally say, ‘Kate, I need you to come here right now!’ I will either get a nasty response or none at all. If she does respond it will take 10 minutes and more nagging before she comes! Why does it have to be that way?!” the beleaguered mother will ask. These parents are good parents of good children. Most of the children whose parents consult me have major or minor neurodevelopmental problems, ranging from autism to ADHD or the kind of organizational problem commonly called “executive function disorder”. All of these problems involve difficulty making transitions. The good mother who is explaining that her daughter does not come when she calls is looking at the top of an iceberg. She sees a little mound of snow or ice. It is a simple, reasonable request. Why can’t her daughter make a “normal” response? However, beneath the water is a huge iceberg of patterned behavior and the meanings associated with it that has been built up over the child’s life.

Let’s analyze the mother’s “simple request” to “come now”. First of all, she is requiring that the child take in the auditory command. This is harder for some children who have ADHD or who have what is called “auditory processing problems” than for others. The mother might not know that Kate has auditory processing problems or if she did hear that from a tester, she may not have entirely understood what it meant. Or even if she did understand what it meant when the tester was explaining it to her, it is hard to keep in mind during the course of family life.

Second, the mother’s command requires Kate to shift her attention from whatever she was doing at the moment to what her mother is telling her. That shift in attention can be much more difficult that you would think. It involves taking apart the current organizational state of the child – her attention, narrative (the story of what she is doing), and her motor activity. It requires Kate to change her postural position and her physiological state of excitement or of comfort, and prepare for something else. Usually, these shifts in our state of being take place out of awareness. We have an intention to change, and it all happens – we stop reading, get up, and walk to the kitchen to start cooking dinner. We don’t realize that all these small changes of everyday life take energy. Other transitions – sleep to wake, home to school, bedroom to bathroom, bedroom to kitchen table, pajamas to school clothes or even worse, snow pants, also take energy. For some children it requires more energy than for others.

In addition to all those shifts, there is the relational and symbolic meaning associated with the transition. For Kate’s mother it may mean, “Oh, dear. I shouldn’t have taken so long reading that paper. I need to get dinner started!” That may be slightly annoying, but no big deal. For Kate, her mother’s calling her may have a very different meaning. That may be something like, “She is bothering me again, just when I got comfortable watching t.v. I had a really hard day at school and Susie was mean to me, and Mom just can’t give me a break. Why is she always making me do things and not Freddie (little brother)!” I am not suggesting that these coherent sentences appeared in Kate’s mind, but that her mother’s reasonable request may feel entirely unreasonable to her, and this meaning comes together with all the other transitional demands – that she shift her attention, her body, get stirred up inside instead of comfortable, etc.

There are two general antidotes for the stress of transitions. One is routine and the other is what I call “herd mentality”. Herd mentality is more available to teachers than to parents of children in small nuclear families. I first noticed it at the orphanage in El Salvador when the little children – most of whom had suffered early neglect and abuse and therefor could be expected from a neurodevelopmental point of view to have difficulty with transitions – all seemed to manage transitions relatively well. I came to think that it was because they all did the transitions together. When it is time to come to dinner and all the other kids start heading in the direction of the dining hall, the stragglers seemed to notice the general movement and catch up, as if noticing that they didn’t want to be left alone. There is another factor – those children didn’t have the hypnotizing effect of video games or other screens to interfere with the process of the transition.

In addition to the herd mentality, there is the importance of routine. What I tell parents is that routine is their best friend. That is because a routine has momentum. The teacher of the children in the preK classroom in the photo above is using routine, herd mentality, and the rhythm of dance, to facilitate a transition. Once you have established a routine the child does not have to move into that state of limbo, an extended disorganized state, with all the stress that entails. (Remember that stress can be expressed as irritability or aggression!) Instead, although the child may not want to interrupt what she is doing to come to the table, it is easier for her to do it. Kate’s mother’s command does not “come out of the blue”. Dinner is at the same time every night, more or less. Kate’s mother has given her a warning five minutes ago, just as she always does. She may even have gone into the family room to join Kate temporarily in her present state (“That looks like a good program! How about if we record it so that you can finish it later!”) and then used her own body to generate a rhythm in the direction of the kitchen. She may also have initiated a conversation about something that interests Kate – “Remember that girl, Karen, who moved out of the school? I just heard that she was moving back!” All these things help establish a routine. Once the routine is established, it makes everything easier.

I am interrupting my blog progression again to talk about a recent infant parent mental health weekend, while it is still on my mind. We heard two terrific lectures last month about temperament and attachment, both subjects of particular interest to me.

The lecture on temperament was again given by Nancy Snidman, the temperament researcher. Nancy defines temperament as “predisposition to respond to the environment in certain ways”. There are many terms to describe temperamental characteristics – for example, introversion and extraversion, fearfulness, sociability, rhythmicity, thrill and adventure seeking, thoughtfulness or empathy, and many more.

One of the most important dialectics is the relationship between temperament and environment. In this case, temperament refers to inherited characteristics and the environment refers to experiences with family, friends, school, and life events. Nancy pointed out that there has been a long history of ways of thinking about temperament. In classical times, the Greeks and Romans thought of temperament in terms of the “humors”. In the 18th century, John Locke deemphasized temperament in favor of the influence of the environment, but then in the 19th century, Darwin focused on the importance of heritable factors in his evolutionary theory. The post World War II period again attributed the most powerful influence to the environment, for example in Freudian theory that gained widespread popularity. However, current research, such as in genetics and neuroimaging, has brought us back to a focus on temperament. Luckily, contemporary theories generally maintain a complex perspective by also including the important influence of the environment.

Some of the variables used by Nancy in studies of temperament deriving from Rothbart infant behavior questionnaire include approach, sadness, activity, perceptual sensitivity, fear, soothability. For example, does the baby get excited when given a new toy (approach), or how sad does the baby get when the caregiver goes away, is the baby easily soothed, does the baby enjoy cuddling?
Nancy reported on a longitudinal study of two styles of temperament – behaviorally inhibited (shy, wary of novelty, slow to approach), and behaviorally uninhibited (sociable, comfortable with novelty). They measured the time it took 31-month old children to accommodate to various novel situations, such as the time it took for them to enter a toy cloth tunnel, the time it took them to approach a robot. Some children behaved in relatively “inhibited” ways, and others were significantly less inhibited. The researchers wondered where this “shy” and “outgoing” behavior was coming from.
Starting with the hypothesis that people have different thresholds of excitability in the amygdala that create different sympathetic nervous system responses, resulting in different kinds of behavioral reaction to uncertainty, Nancy’s research team designed various kinds of auditory, visual, and olfactory stimuli to activate their amygdalas and test their hypothesis. In the lecture, Nancy showed films of 4-month old babies in the experimental situation. The babies were seated in a baby seat, and first one mobile figure was waved in front of him and then another, and then three at once. The first baby sat, attentively watching the moving figures, moving his fingers slightly, calm. The second baby started to fuss as the level of stimulation increased until he arched his back and began to scream. The experimenters studied the frequency and direction of every arm and leg movement, negative vocalization, arched back, etc. The babies sorted themselves out into high reactive babies with “high motor/high cry” and low reactive babies with “low motor/low cry”. Then they studied a group of children from 9-months to 15 years, to see what happened to them.
They were thinking of reactivity in terms of biology. If the amygdala fires, there is sympathetic nervous system activity – arousal, heart rate, respiratory rate. They believe that the biology of the children has a direct effect on their behaviors. If the amygdala is firing and the sympathetic nervous system is “Go!” it will produce behavioral responses. The hypothesis was that the babies who at 4 months were high reactive (high motor/high cry) by 2 ½ years became shy children, and that was because they had inherited a temperament associated with a low threshold of reactivity in the amygdala. These children were what I have referred to previously in the blog as “orchids”.
Across the years, they measured the children’s behavioral and physiological responses – at home at school, and in the lab – to situations that challenged them with different types of novelty or uncertainty. They found that the children moved from simple high reactivity in the youngest babies to a mixture of reactivity and shyness, or inhibition, in the older babies. This shift from high motor activity and high vocalization, to inhibition in the older infants reflects what we know about adults. In some high reactive older infants, when the experimenter changed the tone of her voice from pleasant to harsh as she invited the child to touch a toy, the child withdrew. Over the years, the researchers found remarkable consistency in the reactive style of the children. Some of the high reactive children became less shy, but the uninhibited children did not change. Interestingly, when the high reactive children became comfortable in their environments, they did OK. It was the transitions that are the problem. The high reactive children had more trouble with transitions.
The researchers concluded that there is “strong evidence that infant reactivity is related to a predisposition to have an excitable limbic system” and that this kind of reactivity is a “stable quality over time and situation” (Snidman, 2014). In addition, the research suggests that though these biological factors do not determine anything about the child’s future, and that environment can have an important influence on the child’s behavior and personality characteristics, these biological constraints remain as part of the child’s inherited predisposition.
From my point of view as a clinician, I would stress the value in helping parents understand their children, and teachers understand their pupils, so that they can take the children’s temperament into account when they make expectations of them. Children of all temperaments may be able to achieve the same accomplishments, but they may require different degrees and different types of support in order to achieve them. Earlier blog postings include information related to this subject.

September is a turbulent time of year for young children. Recently, a mother of a preschool boy contacted me to ask me what to do. She asked me about a problem with her son’s sleep and also with an exacerbation of temper tantrums. I will call him Andrew. Three-year old Andrew has always had trouble with sleep, but just before the start of school he began waking up at night and insisting on sleeping in his parents’ room. The temper outbursts seemed random and were shocking to the adults present. For example, recently when his beloved grandmother came for a visit, he ran up to her and punched her. Then he refused to apologize. Andrew’s worried parents were exhausted by his frequent waking during the night and felt helpless to deal with his temper outbursts. Time outs had never really worked for Andrew. His mother asked me for suggestions.

Before giving her mother any suggestions, I visited Andrew at school. This was Andrew’s second year at school, and he was in a different classroom with a larger number of children and more activities. In the classroom, Andrew’s behavior showed that he was excited and proud to be such a big boy. There was a little swagger in his walk as he rushed over to meet his returning classmates with a friendly and confident greeting. However, Andrew’s confident behavior was an over reach. On several occasions his old friends, who were having their own difficulties accommodating to the beginning of school, were unable to reciprocate his exuberant greeting and clung to their parents or held back in preoccupied silence. When this happened, Andrew’s confidence instantly melted. His face fell, his shoulders sagged, and he slouched away from the other child. It was easy to imagine his inner picture of being Big Man on Campus and how catastrophically it collapsed when the reality of his friends being only 3-yo (as of course so was he) interfered with their ability to play their role in his grandiose fantasy.

Andrew had a similar reaction to a mild correction by a teacher. He had readily and apparently magnanimously given up a toy car to another child who requested a turn, but as it turned out, he hadn’t really had a chance to think it through. He had been playing a wonderful game of collecting pebbles and sticks from the playground for one of his new teachers. His enthusiasm had recruited another classmate in the activity, and they had been happily wheeling around the playground. After a while, his attention strayed and he left the car, which was then claimed by the second child. At this point, Andrew looked around at the other child whizzing off in the car, and his disappointment was obvious. “Now what can I do?” he muttered under his breath. After grumpily refusing multiple alternatives from another teacher, he settled on a smaller vehicle and began pushing it across the playground surface. His friend from the previous activity joined him in this fast-paced game, and his good mood seemed recovered. Then, suddenly a third teacher announced – in a perfectly friendly manner – that children must sit on the seat; pushing the vehicle was not allowed. Again, Andrew’s face and body were transformed into a thundercloud. This time he fell to the ground and hid his face in his hands.

You can see how exhausting a morning it was for Andrew, and it was only 9:30! Insight into the mind of a child like Andrew can guide his parents in their decisions about to handle his sleep problems and his tantrums. After considering what is in Andrew’s mind, his parents might tell him, “You are working so hard to be a big boy, and we are so proud of you. But sometimes you get tired out and can’t act like a big boy any more.” They might then comfort him and assure him that they believed he could “be a big boy again tomorrow”.

They decided to let him sleep in their room for a couple of weeks while he managed the transition to school, with a planned, graded, return to his own bed facilitated by rewards. This approach had the advantage of offering him the support he currently needed with an additional built-in transition-practicing exercise. (By this I mean that the planned return to his bed was another chance to practice making transitions.) In addition, a procedure like this reinforces the link between his inner experience (distress about transitions) and his behavior.

With regard to the assault on his grandmother, they concluded that an apology was too much to expect at the moment. If another such incident occurred, they agreed that they would take his hand and apologize to his grandmother for him (after giving him a chance first) and explain to the grandmother that he was having a hard time recently with starting school, and sometimes his body just bursts out with a mad behavior like the punching (another chance to link the inner experience with the behavior, modeling for him self reflection) and you know he is very sorry about it even if he can’t say it right now. Then, later, they would give him the chance to do something nice for her in reparation.

Ben has continued to grow in his capacity for language and friendship. He is a happy child who loves his parents, his teachers, and his friends. He also seems to love school and the activities in the classroom and the playground.

In a brainstorming session in the classroom earlier in the year, his parents and teachers and I tried to come up with a plan that would make it easier for Ben to make the transition from bed to school. Although as I noted he loves school, he had a hard time making the transition from bed to getting ready for school in the morning. The teachers wondered if his parents could give him a job to do in the morning, since Ben delights in the jobs (meeting assistant, snack helper, etc.) he has at school. His parents followed through, and sure enough the job solution seemed to help the morning transition. The last time we spoke, his mother said that helping his father make breakfast or even do the laundry (which everyone agreed was a less desirable job) facilitated the move from sleep state and cozy bed and mommy, to school.

It is important to add at this point that there is nothing magical in this kind of “strategy” and nothing that ensures that this particular good idea will help another child in another place and time. Yet, the idea emerged from a sharing of observations and impressions of Ben among important people in his life, and this collective effort to understand Ben is valuable in itself. The idea of a “job” was specific to one little individual, Ben, but I would guess that whenever teachers and parents engage in this kind of constructive process with or without someone like me, a similarly useful idea will result.

Another related thought is that “strategies” (parents and teachers frequently request them) are sort of Wizard of Oz phenomena. That is, their power may derive as much from the caregiver’s subjective response to them as to their inherent value. (I often think the same about medicine; perhaps some of the placebo effect is related to this.) If the caregiver asking for a strategy trusts in the wisdom of the authority – whether a person or a book – then the strategy has the potential of being helpful. The strategy and the authority behind it confer a sense of security or hope that works against the original helplessness experienced by the caregiver, and those positive feelings are communicated to the child.

And one more thought I have on the subject is that these strategies are placeholders in the child’s development. They can help children avoid getting stuck in their developmental paths and maintain their momentum so that they can continue to grow until the solution to a problem specific to one point in time is no longer needed.

“Ben” was born after a difficult pregnancy and had “the worst colic (their experienced pediatrician) ever saw”, crying for 10-15 hours per day until he was 4 months old. Because of gastric reflux, he was put on numerous medications and a gluten free diet. Ben is also over reactive to sensory stimuli– stressed by sounds and sunlight, and particularly by touch – , making bathing, diaper changing, and wearing clothes aversive! His parents describe him as always preferring to be in motion. He has seen many specialists and has received OT and speech therapy.

At age 2, he entered preschool. Ben’s classroom has a calm but playful atmosphere, a predictable routine, a small number of children, and three skilled teachers. In this environment, Ben began to make strides in his development. Although his teachers delighted in his sense of humor and in the rapid progress he was making, his parents continued to struggle with meltdowns at home. They described him as a 24/7 occupation. They were worried about having a second child. How could they manage another when they were so busy with Ben?

In particular, Ben’s parents noted his difficulty making transitions. Although he loves school, he often refuses to go downstairs in the morning in order to get ready. He may have a tantrum about getting into the car to go to school. In addition, not surprisingly, he makes a fuss about going to bed at night.

One day, I encountered Ben on the playground. He was crying softly and burying his head in his teacher’s chest. There was a light rain that morning, and raindrops were making dark spots on Ben’s shirt and sweat pants, and even glistening on his hair and forehead. His teacher was holding a raincoat in her hand and attempting to persuade Ben to put it on. She explained to me that Ben did not like to get wet, but he didn’t want to put on the raincoat. She asked Ben why he didn’t want to wear it, and he just shook his head and continued to cry, explaining only, “I sad.” Acknowledging that maybe Ben himself did not know what was making him so sad, his teacher and I continued to imagine why he was crying. Maybe he did not want to wear a different raincoat, since his own raincoat had been left at home and this raincoat was from the lost and found. Maybe he didn’t like the feeling of a coat on his body anyway. Also, he didn’t like to get wet! Maybe he was crying because of all of these things.

Eager to draw from the teacher’s experience, I asked her what she had tried and what she was going to do. She explained that they had a rule that children must wear raincoats if they wanted to play in the rain, and that otherwise they had to go inside. Ben cheerfully said he wanted to go in. His teacher said that he could go in, but she also knew he wanted to play with his friends, and he couldn’t play with his friends if he went inside. Ben looked confused and unhappy. The teacher consulted her watch. She told me that there were only a few minutes left of their outside time, and that she was inclined to let him stay outside and change into dry clothes after all the children returned to the classroom. This was the “choose your battles” approach. I asked her what she would do if the circumstances were different. She said that if it were pouring rain, she would insist on his putting on his coat if he chose to stay outside in the rain and refused to go in, even if she had to physically help him put it on. Often parents and teachers are reluctant to take the concrete initiative to help a child put on his coat. However, I have found that sometimes doing so has a good result; once the initiative has been taken, a momentum is established that makes it easier for the child to collaborate. Of course, one wishes to support the child in taking his own initiative, so encouraging him to do so is the way to begin. Only if that fails would I take the lead. It is always important to have many strategies available.

What was most impressive about the whole situation is that when I called Ben’s mother afterwards to follow up, she told me that Ben had explained the whole experience to her after he came home from school. He told her about not wanting to put on the raincoat, that it wasn’t his raincoat, that he was getting wet and that made him sad, but that he had wanted to play with his friends. I reflected on the remarkable learning experience this had been for Ben. In Ben’s presence, his teacher and I had discussed slowly and thoughtfully the meaning we made of Ben’s dilemma and some possible solutions. We noted that Ben didn’t like any of the solutions we suggested. We came up with others. He didn’t like these either. There was a way in which Ben’s rejection of our suggestions enhanced the learning experience by drawing out the reflective process, by allowing him to consider more and more possibilities, by helping him see that there was a bigger territory in between all or nothing than he had realized, even if he could not bring himself to choose one of those options. Finally, in telling the story to his mother, he engaged in the active process of creating new meaning of his own of his experience. In remembering, in choosing the words to fit the memory images, in making himself known to his trusted and beloved parent, he took a small step into a mind of his own.

I believe that through a repetition of small growth experiences like this Ben will learn how to make transitions more smoothly, because he will be making them in an expanded repertoire of choices.

Jerry is a 13-year old boy who will not get off the computer. His mother in particular gets into terrible struggles with him when it is time to do his homework and he is intensely involved in a computer game that he refuses to leave. If it were not for his homework, his mother would not object as much, since he is developing skills in fine motor coordination, pattern analysis, and quick reaction time – to say nothing of his facility with computers! – And also he often engages in interactive games with his friends, which are collaborative as well as competitive and highly social. The main problem is that he does not do his homework. As soon as he comes home from school, he rushes to his computer and begins a game. When it is time for homework, supper, or bed, he refuses to get offline. (In response to a NY Times column about the subject, I found interesting comments from parents.)

It is not that Jerry does not care about school. He is very ambitious and conscious of the success of his slightly older sister, with whom he is highly competitive. He is discouraged about his school record and dreads receiving his report card, but he seems unable to accept help. When his teachers offer him extra help, he usually politely thanks them but does not show up for the scheduled session. He refuses any regular tutoring assistance. Last year he would ask his mother or father to sit in the room with him while he did his homework – although he would not allow them to help him in any concrete way – but this year he refuses any support from them. This drives them wild with feelings of worry and helplessness.

Jerry has always been an active, rather disorganized child, interested in sports and fairly good at them, but intense and prone to tantrums. He has such a short fuse that his parents and sister have tended to monitor his moods closely and when he is in “a bad mood”, “walk on eggshells” to avoid an outburst. His parents have extended themselves in many ways to try to make things better for him. They have helped him play the sports he choses and attended all of his games. They have advocated for him fiercely at school. Still, family life has been hard.

His mother says that when he is on the computer he is happy and excited, and completely involved. When he gets off the computer, he falls apart – becomes irritable, disorganized, infantile, and sometimes aggressive. When he acts like this, she tries to negotiate with him, but his negative behavior just escalates until a blowup. After that, when she tries to talk to him about what just happens, he either blows up again, or he leaves and slams the door behind him. His father sometimes has more luck with soothing him when he is irritable, but he is not much better at getting him to leave the computer or do his homework. His mother feels that she is always “the heavy” and expected to set limits and keep order in the home, while her husband comes and goes when it serves him. Sometimes she thinks that if he were “more present” as a father, Jerry would not be in trouble – and when she is at her wits’ end, she will tell him so – but other times she acknowledges that there is no simple answer for Jerry’s difficulties.

Both Jerry’s parents came from modest backgrounds and were exceptionally high achievers as children and adolescents. They now both have successful professional careers, though perhaps not at the level or degree of satisfaction that they had envisioned. Whereas his father had studied at Julliard and had imagined a career as a performing musician, he now teaches at a private school and works at composing music in his spare time. His mother, who had won national prizes as a figure skater, is now a coach.

This story is an elaboration of the “transition to school” posting, since it also involves homework. There is an excellent set of posts on the Child Mind Institute on transition to school that can be helpful to caregivers. They include good strategies to try first. A colleague has written a thoughtful blog post about the transition to kindergarten. Many of the children whose parents consult me have tried or could try these strategies without success. The story of Jerry is an example of such a case. My posting is to remind caregivers that each child is unique and has an inner world of his own, so that general strategies – no matter how intelligent or thoughtful – are sometimes not the answer. Rather, trying to imagine what is going on inside the child’s mind is the best way to start every effort to scaffold a difficult transition. Let me know what you imagine about what is in Jerry’s mind.

Courtney is a charming, gregarious, 4-year old African-American girl who will not go to bed at night. For 3 years, she has insisted on sleeping with her mother, and her father, who came from Haiti to Boston as a teenager, has long since slept alone. She is a restless sleeper and kicks her mother in her sleep, keeping her mother awake. The pattern began with the coincidence of two adverse events in the family. At 1-year old, Courtney was hospitalized briefly with bronchiolitis, and after her hospitalization she was diagnosed with asthma. At the same time, her father took a second job driving a taxi in order to meet the needs of his expanding family (he had two children from a previous family that he was helping to support).

After bringing Courtney home from the hospital, her mother took her into her bed to make sure she was breathing normally during the night. Her father went back to work at night and returned late in the morning. Courtney’s mother does not work outside the home but cares for two other children in an informal day care arrangement. Courtney’s mother is a beautiful young woman but looks tired and wan. She has lived in Boston for about 6 years now. She moved to Boston with an older sister from South Carolina, but her sister didn’t like the city and returned to the South. By that time, Courtney’s mother had met her now husband and decided to stay.

Courtney began kindergarten at the public school several months ago, in September. Her teacher described her as “active and curious”. She told her mother that Courtney had a hard time sitting still in circle time and had to sit next to the assistant teacher for support. Her speech was immature, and she was often disorganized and needed help following the classroom routine. She also told her mother that Courtney sometimes put her head down on her desk and seemed tired; the teacher asked her mother if Courtney were getting enough sleep. Courtney’s mother was unhappy with the progress reports, because she felt the teacher “did not know” Courtney. She thought that Courtney was smarter than her teacher gave her credit for. She also felt blamed by the teacher’s suggestion that Courtney might not be getting enough sleep.

Courtney’s mother is stricter with Courtney than with the other children in her care. She tells Courtney that she wants her to “grow up to be somebody”. She also reminds her that the way she can do that is to “do good in school”. She is determined to help her daughter succeed and worries that the school will not do their part. She gets very frustrated with Courtney for not sleeping in her own bed. She tells her, “When I was growing up, I had to sleep in a bed with three kids! Now you have a bed of your very own, and you won’t sleep in it! What’s the matter with you?!”

Here is the second illustration of a child and caregiver, again the mother, having difficulty negotiating a transition. Again, I welcome comments from different types of child caregivers.

b. Transition to School:
Daniela is a 9-year old girl who refuses to go to school. It is now October, and she has missed 10 full days of school and come in late or left early at least another dozen times. This is very hard on her single mother, whose boss has told her she cannot miss more time from work. The last few times, her mother has left her at home, watching t.v.

Daniela lives with her mother, who emigrated from Central America 10 years ago, in a studio apartment in city housing. She has never met her biological father, also from CA, but she calls her mother’s former boyfriend “Daddy”. Her mother told him to move out last year after a particularly violent fight. Her Daddy comes to see Daniela episodically and takes her to play at his mother’s apartment, where there are other children that the grandmother takes care of. Daniela enjoys these visits but sometimes is intimidated by the other children, especially an older boy.

Daniela is a quiet girl who has attends fourth grade at a public school in her city. Spanish is the only language spoken in her home, but her mother chose to have her enter an English only school so that she would learn English, and she quickly became fluent. Her mother’s English is minimal, and outside the home, Daniela often translates for her. Daniela seemed to do well in the first three years of school. She enjoyed going to school, and her progress reports described her as a bright, friendly girl with an aptitude for language and who was at least an average student in math. She had a few girl friends and was very attached to her teachers. Her kindergarten teachers and the teachers who taught her combined first and second grade classroom had the reputation of being the best teachers in the school. One teacher in each classroom spoke Spanish and a good relationship with Daniela’s mother.

However since last year, she speaks barely a word at school. Her mother blames the school for Daniela’s school refusal, because last year there were some bullies in her class. One boy in particular picked on her, making fun of her clothes and even making vulgar sexual remarks. The boy is not in her class this year, but she sees him on the playground at recess. Her mother wanted the school to expel the boy, but she was told that they could not do that. Also, for the past two years, Daniela’s teachers have not been as sympathetic to her or to her mother as her mother considers appropriate. They have told her mother that Daniela needs to make a bigger effort to participate in school, that other girls have tried to engage her, sit next to her at lunch, but Daniela does not respond.

Daniela began to fall behind in her schoolwork last year for the first time. She would tell her mother that she had no homework or had already done her homework, but later her teacher would send home notes telling her mother that Daniela’s assignments were missing or incomplete. This would make her mother frantic, and she would scream at Daniela to show her homework, but Daniela would only shut down.

Just before I left on vacation, a mother of a child in my practice asked me why it was so hard for her 6-yo son to make transitions. I was rushing to get ready to leave, so I sent her a quick email promising to respond more fully when I had a chance to think about it. I have had her question in the back of my mind and was especially struck by it when I arrived in Europe and experienced jet lag. It occurred to me that jet lag was a good metaphor for the kind of transition the mother was asking about.

First of all, her child is one of those highly sensitive children I refer to as “race horses”, of others in the literature have called “orchids”. He is extremely intelligent but sometimes retreats to infantile behavior patterns, and he often reacts with extreme distress in the context of transitions – even simple daily transitions such as getting up and getting ready for school in the morning or leaving play to go somewhere or do something else. This problem is interesting because it gets mixed up with all sorts of other categories of problems – such as problems with compliance (behavior problems) or sensory over-responsivity problems (SOR) (Ben-Sasson et al, 2010).

I think there are reasons for this confusion.As writers on “orchid” children point out, it is easier for children with certain temperamental characteristics to readjust to changes in their environment. (I chose the above photo of young Indian dancers because I imagined – though I do not know these children – that the girl on the left has an easier temperament than the girl on the right.) These delicate children are often much harder to parent than children with easier or more resilient temperaments (“dandelions”), and parents and child often initiate problematic interaction patterns early on that can influence the child’s developmental trajectory in an unfortunate direction. It then becomes the job of the child therapist to help the family (child and parents) correct this misdirection.

The kinds of problematic patterns that are characteristic of this situation typically involve mutual over-control. That is, children who feel highly stressed by demands for change (in other words, transitions) often try to exert a counterbalancing force by controlling their environment (their parents, included). Parents may respond either by engaging in a control struggle with the controlling child or by giving in, or by both (Granic, 2006). When these patterns are repeated, they become more firmly rooted in family behavior. I refer to this as building stronger infrastructure for the problem cities (metaphor for problematic relational patterns such as struggles in families) so that it is easier to get there and stay there. Of course, it is better for all involved to build strong infrastructure for the cities that represent more adaptive behavior patterns such as collaboration, but when people are stressed, they often choose the behavior that takes less energy (from the point of view of managing emotions and using reflective capacity) in the short run and more energy in the long run (having to repair the ruptures that struggles and fights cause in the family).

The job for child therapists is to work with child and family to “break the habits” of the problem behaviors and substitute more adaptive patterns. This is done by a variety of techniques including gaining insight into the meanings underlying the behavioral reactions of child and parents and supporting the emotional regulation of all concerned, and then … practicing the new more adaptive patterns again and again and again. I will write more about this important aspect of the topic in a future posting, but I will limit myself here to the mother’s question of “why?”

Let me return to the metaphor of jet lag. My intention is not only to respond to “why” a child has trouble with transitions, but also to offer a way of empathizing with the irritable child. (Often, a parent empathizing with the child allows her or him to better imagine the child’s mind and this can facilitate the parent’s choice of response to the child’s demanding or oppositional behavior). I found a good article on jet lag that describes it in terms of whole organism dysregulation (Vosko et al, 2010). Circadian rhythm – sleeping longer at night and less during the day – is one of the first organizations to emerge in the developing newborn (Sander, 2008). It is achieved through a series of oscillatory networks that include a master oscillatory network in the suprachiasmatic nucleus (SCN) in the brain and also sensitivity to environmental light cues (Vosko, p. 187). During jet lag, the paper continues, abrupt changes in the environmental light-dark cycle desynchronize the SCN from downstream oscillatory networks from each other, disrupting sleep and wakefulness and disturbing function (ibid, 187). This kind of “circadian misalignment” can lead to a series of symptoms, including major metabolic, cardiovascular, psychiatric, and neurological impairments (ibid, 187). During this trip, as usual, my jet lag “took over”. Although I intended to stay awake and enjoy the company of my friends and the new landscape, I was compromised in my ability to do so. The feeling of dysphoria came in waves; sometimes I felt my old self again and other times I felt tired, irritable, and even sick.

The benefit of this metaphor is that it emphasizes the notion of whole human being “organization”. Many problematic behaviors result from a disorganization of adaptive patterns of functioning. The human organism is constantly working to keep itself on track and to accommodate small bumps and disruptions. It is when the reorganization does not happen smoothly, when things fall apart, that a “symptom” appears. The symptom can be physiologic as well as emotional, just as in jet lag. Children who have delicate temperaments or other developmental reasons for high sensitivity (such as children with ASD, uneven development, trauma, or SOR) are particularly vulnerable to this problematic disorganization.

Consider all the demands for reorganization that a child has to respond to on a daily basis: She has to wake up, changing from a sleep state to an alert state. She has to get up and get ready for school, requiring many transitions from the multiple small tasks involved in washing and dressing. She has to eat breakfast, even if she is not hungry at the time. She has to say goodbye to home and parents and make a big shift from a relatively dependent position to a more autonomous position in terms of initiative and compliance. When she gets home from school she has to deal with other important transitions. Don’t think for a moment that greeting a beloved parent is necessarily going to be a pleasant experience; the transition from a holding-it-together-at a higher-level-of-organization-state at school to a more relaxed and dependent one at home is often bumpy! In addition, often parents of sensitive children give them aids to help them keep organized in the transition, such as video games. As I have mentioned in another posting, these games work very well to keep a child organized because they provide an effective external regulator. When this external source of regulation is taken away abruptly, it can be expected to cause great distress. Even a book, a much more adaptive regulating activity, can cause distress when discontinued.

What is the answer to these problems? I will respond in a subsequent posting!

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About

Alexandra Murray Harrison, M.D. is a Training and Supervising Analyst at the Boston Psychoanalytic Society and Institute in Adult and Child and Adolescent Psychoanalysis, an Assistant Clinical Professor of Psychiatry, Harvard Medical School at the Cambridge Health Alliance, and on the Faculty of the Infant-Parent Mental Health Post Graduate Certificate Program at University of Massachusetts Boston. Dr. Harrison has a private practice in both adult and child psychoanalysis and psychiatry. In the context of visits to orphanages in Central America and India, Dr. Harrison has developed a model for mental health professionals in developed countries to volunteer their consultation services to caregivers of children in care in developing countries in the context of a long term relationship with episodic visits and regular skype and video contact.